Management of breast abscesses in Jamaican women is there need for a paradigm shift?

A paradigm shift from operative to non-operative management of breast abscesses has occurred in surgical centres worldwide. The recent experience in managing these patients at the University Hospital of the West Indies (UHWI) was examined. Data were obtained retrospectively from dockets retrieved from the UHWI medical records department, and were analysed using the SPSS version 11.0 software package for Windows. Seventy-seven patients with breast abscesses presented during the 66-month study period, but complete data were unavailable for seventeen cases. The mean age of the remaining sixty patients was 32 years. There was one male patient. There were no cases of bilateral disease, and the majority was right-sided. Mean white blood cell count at presentation was mildly elevated at 11.9 x 10(9)/L, and had no relationship to method of management or length of stay. There were two cases treated with aspiration and antibiotics only. All other cases were treated with incision and drainage. Culture results were available in forty-four cases, and in 80%, Staphylococcus aureus was identified, with one case of methicillin resistant Staphylococcus aureus. The mean delay to the operating theatre was one day after presentation and the mean length of stay was 4.5 days. Seventeen patients had a 'non-cosmetic' incision. The traditional management of breast abscess provides challenges in terms of delay to the operating theatre and prolonged hospital stays. There is increased expense, as well as loss of productive work hours, associated with this line of treatment. Non-operative management has not traditionally been undertaken in our institution, but it is documented elsewhere to be safe, practical, and results in improved cosmetic outcomes. Prospective protocol-based trials are necessary to identify the patients most suitable for this line of management in a setting with limited resources.

Laparoscopic colectomy for colonic neoplasms in a developing country.

AIM: To report the outcome of patients treated for colonic neoplasms using a laparoscopic assisted technique since its introduction at the University Hospital of the West Indies, Jamaica. SUBJECTS AND METHODS: All consecutive patients undergoing laparoscopic assisted colectomy were entered into a prospective database and this data analysed. Data collected included patient demographics, pre-operative diagnosis, operative events, post-operative morbidity and outcome. RESULTS: Over the thirty-six months period July 1, 2005-December 31, 2005 and July 1, 2006-December 31, 2008, thirty patients each underwent laparoscopic assisted colectomy for a colonic neoplasm. Their mean age was 63 years with M: F ratio of 1:2. Seventy-four per cent of the patients had carcinomas which was located on the right and sigmoid colon in 17 and 10 patients respectively. Mean operative time was 98 min for patients with right-sided lesions and blood loss for the entire group was minimal. Two patients were converted to open resections. Median duration of hospitalization was five days. There was no mortality but three patients had complications. After median follow-up of 30 months, there was no local or systemic recurrence. CONCLUSIONS: Appropriately selected patients with colonic neoplasms can be safely subjected to a laparoscopic assisted resection and expect to enjoy the advantages of this technique even in a developing country setting. The outcome of thirty consecutive laparoscopic assisted colectomies is reported demonstrating that this technique can be safely applied to selected patients with colonic carcinomas in developing countries.

Duodenal fibrosarcoma mimicking Franz tumour complicated by post-resection chylous ascites.

This case report presents a young woman who underwent a Whipples resection for a large pan-creato-duodenal tumour. Pathology and immunohistochemical analysis of the tumour suggest duodenal fibrosarcoma. The patient's postoperative management was complicated by chylous ascites. A brief literature review is given to highlight this unusual case.

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated?

INTRODUCTION: A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC). METHODS: To determine the outcome of STC in this high-risk group, we retrospectively reviewed the histopathology reports and case records of all subtotal colectomies performed for LGIB over a 8-year period. RESULTS: Fifty-eight patients (mean age: 71 years; male to female ratio, 1 : 1) underwent emergency surgery for unlocalised LGIB, 45% of which were massive on admission, and unresponsive to resuscitation. The remainder had persistent or recurrent bleeding during the index hospitalisation. The hospitalisation for colectomy represented the first for LGIB for 56% of the study group, while 38% were on at least their third such admission. All but three patients underwent preoperative rigid proctosigmoidoscopy. Fifty-five of the 58 patients were treated with STC and primary ileorectal anastomosis. The major causes of bleeding were diverticular disease only (68%), angiodysplasia only (12%) and both diseases (12%). Overall mortality was 17%, with the main contributor being sepsis resulting from anastomotic leak. Non-fatal complications occurred in 20%, resulting in a mean postoperative length of stay of 13 days. All patients were doing well on their first follow-up visit with a mean number of four stools per day after 1 month. CONCLUSION: While emergency STC is an effective and definitive method of treating unlocalised massive LGIB, its associated morbidity and mortality may limit its usefulness.

Postoperative nausea and vomiting in laparoscopic versus open cholecystectomy at two major hospitals in Jamaica.

Postoperative nausea and vomiting (PONV) is a distressing and potentially dangerous complication of general anaesthesia with volatile agents. The internationally reported average risk is 20 to 30%. It has been suggested that Jamaicans have a generally low risk of PONV and this is plausible since ethnic-based differences in response to emetogenic stimuli have been identified. It has also been suggested that laparoscopy, by stretching and irritation of the peritoneum during gas insufflation, may be a risk factor for PONV but it has become increasingly difficult to test this hypothesis as fewer comparable open abdominal operations are being performed. This retrospective cohort study of PONV after laparoscopic versus open cholecystectomy was designed to answer these two questions. Data were collected on 356 cases performed at two major hospitals in Jamaica. The risk of PONV after laparoscopic and open cholecystectomy was 28.7% and 28.6% respectively. As these are at the upper end of the internationally reported average range, the impression that PONV risk is generally low in Jamaicans is not supported The finding that 81.4% of cases of PONV occurred only after discharge from the recovery room may explain the misconception. There was no significant difference between the risk of PONV after laparoscopic versus open cholecystectomy and the effect of laparoscopy remained insignificant after risk-adjustment in a generalized linear regression model. Laparoscopy is not a major risk factor for PONV in this study.

Clinicopathologic features of breast disease in Jamaica: findings of the Jamaican Breast Disease Study, 2000-2002.

OBJECTIVE: To describe the clinicopathologic profile of breast disease in Jamaica. METHODS: The Jamaican Breast Disease Study is an ongoing prospective, multidisciplinary investigation of breast disease at the University Hospital of the West Indies (UHWI). The initial phase was a prevalence survey comprising all consenting patients referred to the Surgical Outpatient Department (SOPD) UHWI, for breast disease. Demographic, clinical, radiologic and pathologic information were recorded for each patient and the data for the first three years (2000-2002) were analyzed. RESULTS: A total of 1189 patients was enrolled for the study period (28.8% of all new SOPD patients). The age range was 10 to 93 years (mean/SD = 36.5 +/- 16.4 years) with a female : male ratio of 14:1. Most patients (67.8%) presented with a palpable lump and the clinical diagnosis was benign in the majority (70.4%) of patients. Fibroadenoma was the most common benign histologic result (39.4% of all biopsies) followed by non-proliferative (fibrocystic) disease (19.3% of all biopsies). Proliferative disease without atypia, complex fibroadenoma and atypical ductal hyperplasia accounted for 6.9%, 2.6% and 0.4% of biopsies respectively. Overall, 23.4% of biopsies showed malignant histology (10.8% patients); invasive ductal carcinoma accounted for the majority of these cases (69.5%). CONCLUSIONS: The majority of patients with breast disease in Jamaica are young women with clinically benign disease. There was a low prevalence of clinically significant premalignant disease. This is the first study to prospectively describe the clinicopathologic features of breast disease in Jamaica and supports the need for advocating breast cancer screening to facilitate detection of significant premalignant disease and early stages of breast cancer.

Management of obstetric anal sphincter injuries at the University Hospital of the West Indies.

Up to 6% of women sustain severe perineal lacerations that involve the anal sphincters during vaginal delivery. When they occur obstetric anal sphincter injuries (OASI) may be accompanied by significant morbidity. Therefore, it is important to detect these injuries promptly and for experienced staff to perform sound repair. This report retrospectively assesses a series of seven women with OASI who were managed at a tertiary level hospital in Jamaica over a period of 28 months. Unfavourable details of management that may have adversely affected outcomes were sought from the various cases treated The incidence of OASI was low (0.2%). There were five third degree and two fourth degree lacerations. After these injuries were repaired, three patients (43%) experienced morbidity such as chronic pelvic pain (43%), anal incontinence (29%), dyspareunia (23%) and recto-vaginal fistulae (14%). In order to improve the outcomes at this institution, several aspects of current care can be improved. Operative repair of these injuries should be delayed until senior staff is available to supervise OASI repair. Both methods of sphincter repair are reasonable options but the use of rapidly absorbable sutures is not appropriate. Finally, prophylaxis against wound infections can be achieved by administering a single dose of intravenous second or third generation cephalosporin at the time of induction of anaesthesia.

Emergency department thoracotomy in Jamaica: a case controlled study.

Increasing numbers of severely injured patients have been presenting to Emergency Rooms worldwide due to advances in pre-hospital trauma care. Some of these patients may be candidates for Emergency Department Thoracotomy (EDT). Large advisory bodies have identified selection criteria for EDT in Developed Countries, but there are no regional statistics to guide the selection process in Developing Caribbean Nations. This study evaluates outcomes with EDT at the University Hospital of the West Indies in Jamaica in order to determine factors that could predict survival in this setting. A retrospective study was performed over 11 years from January 1995 to January 2006 examining patients who had EDT at the University Hospital of the West Indies. There were 13 procedures performed over 11 years, with two early survivors (15%) and one patient surviving to discharge. The factors that have been found to be significant predictors of mortality include gunshot injuries, extra-thoracic injury location, inadequate pre-hospital resuscitation, prolonged transportation time and the absence of signs of life on arrival to hospital. Several health care limitations have been uncovered in this setting that must be improved if we are to expect improved outcomes. Focused preparation of the Emergency Room is an initial step that can be easily achieved. We also need to define strict management protocols using selection criteria that are tailored to our local environment in order to exclude futile procedures in unsalvageable patients.

A comparison of open and laparoscopic cholecystectomy done by a surgeon in training.

Laparoscopic cholecystectomy has virtually replaced conventional open cholecystectomy as the gold standard for symptomatic cholelithiasis. The laparoscopic approach brings numerous advantages at the expense of higher complication rates, especially in training facilities. This comparative 18-month review examines the outcomes of 52 cholecystectomies performed by a single surgical resident at the University Hospital of the West Indies--a teaching hospital in Jamaica. The advantages of laparoscopic cholecystectomy have been demonstrated and it has been found to be safe and effective in this training facility.

Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients with sickle cell disease: preliminary experience.

Laparoscopic cholecystectomy, with its advantages of reduced postoperative pain and shorter hospitalization is the accepted standard of care for patients with symptomatic cholelithiasis. A retrospective study was done to assess the outcome of laparoscopic cholecystectomy in patients with sickle cell disease, a group known for its high postoperative morbidity. The study sample comprised of patients seen at the University Hospital of the West Indies during the period 1999 to 2004. Twelve patients were females and four were males. Their mean age was 28.5 years (range 13-43 years). Fifteen underwent elective cholecystectomy for recurrent episodes of cholecystitis while one patient required an emergency procedure. All patients underwent endoscopic retrograde cholangiopancreatography, which successfully removed common bile duct stones which were present in 25% of the cases. There were four conversions to open cholecystectomy as a result of obscure anatomy due to scarring and adhesions. The duration of surgery ranged from 70-150 minutes. Six patients developed postoperative complications, four of whom had acute chest syndrome. This resulted in death in one patient. The mean postoperative hospitalization period was 5.5 days. This report indicates that patients with sickle cell disease remain a high risk group with the potential for significant morbidity even when subjected to minimal access surgery.

Bile duct injuries in the laparoscopic era: the University Hospital of the West Indies experience.

During the ten-year period July 1994 to June 2004, 20 patients were seen with iatrogenic bile duct injuries. The case notes of these patients were reviewed. Half of the patients were referred after initial surgery at other hospitals. At the University Hospital of the West Indies, bile duct injury rate was 0.8% and 1% for open and laparoscopic cholecystectomy respectively. Sixty per cent of patients' injuries resulted from open cholecystectomy and the majority of these were during emergency cholecystectomies for acute cholecystitis. A wide range of treatment modalities were employed for patients with minor bile duct injuries but Roux en Y hepaticojejunostomy was the treatment of choice for patients with transection of the common hepatic or bile duct. Follow-up was available in seven of nine patients who had major bile duct injury repair to a median of 36 months and all but one were asymptomatic and had normal liver function tests. There were two deaths because of septic complications.

Selective operative cholangiography in the performance of laparoscopic cholecystectomy.

The objective of this prospective study was to evaluate the role of intraoperative cholangiography (IOC) for patients undergoing laparoscopic cholecystectomy (LC) to determine whether it could be safely omitted for all patients who fit standard criteria, namely normal liver function tests, no history of gallstone pancreatitis, common bile duct (CBD) diameter less than 10 mm or previous history of jaundice. Data were collected prospectively from 194 consecutive patients who had LC for symptomatic gall bladder disease. IOC was not performed in any patient. The conversion rate was 6.1% and one CBD injury occurred. Our experience demonstrates that LC performed without routine IOC does not result in an increased incidence of retained stones in selected patients who have no history of pancreatitis, normal liver function tests and CBD less than 10 mm diameter.

Endoscopic retrograde cholangiopancreatography use at the University Hospital of the West Indies.

All patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at the University Hospital of the West Indies (UHWI) were entered into a prospective database. Parameters included demographics, indication for the procedure, success of the ERCP and any immediate complications noted. Retrospectively, the patients' case notes were analyzed for complications developing after 24 hours, and outcome. During the period March 1999 to December 2002, a total of 120 consecutive patients were subjected to 123 ERCPs, all being performed by a single gastroenterologist. Of these 120 patients, eight had ERCP as outpatients and were transferred back to their referring hospitals. These patients were excluded from further analysis. Of the 115 UHWI patients, the case notes of 96 were available for analysis and this group formed the basis of this review. ERCP had successful cannulation in 95% of patients. There were 70 females and 26 males with a female to male ratio of 2.7:1. Age ranged from 13 to 85 years (mean +/- SD, 43 +/- 17), males being an average six years older than females. The most common indication for ERCP was a patient with cholelithiasis and abnormal liver function tests scheduled for laparoscopic cholecystectomy. This made up 33% of patients and in this subgroup, sickle cell disease accounted for 50% of cases. Patients with common bile duct stones preoperatively and post-cholecystectomy accounted for 13% and 17% respectively while gallstones pancreatitis accounted for 13% of cases, including three patients with severe pancreatitis. While 64% of the patients had normal cholangiogram, 66% of them had sphincterotomy. Common bile duct stones were seen in 23 cases and complete removal was successful in 48%. There were ten cases (10%) of ERCP pancreatitis and this was severe in three patients and the direct cause of death in one. One patient had ascending cholangitis post ERCP and there were no cases of post-sphincterotomy bleeding or duodenal perforation. Endoscopic retrograde cholangiopancreatography at the UHWI has high diagnostic yield but its therapeutic use needs further development.

Biliary surgery in sickle cell disease: the Jamaican experience.

Of 62 patients with homozygous sickle cell disease subjected to open cholecystectomy for symptomatic gallstones over a 12-year period at the University Hospital of the West Indies, 25 were males and 37 were females. Of these, 27 were paediatric patients aged 18 years or less, and 35 were adults. Preoperative transfusion was selectively administered. All cases presented with right upper quadrant pain and 15 of 62 with obstructive jaundice. Mucocoele of the gallbladder, empyema of the gallbladder and common bile duct stones were detected in 2, 2, and 23 patients, respectively. Exploration of the common bile duct was necessary in 31 cases and a T-tube sited in 15 cases. Twelve of the 62 patients developed acute chest syndrome post operatively (20%). There were 2 deaths, both occurring in patients who had developed acute chest syndrome; in a 34 year old and a 10 year old patient. Common bile duct related morbidity was proportionately more common in paediatric patients than adults, represented by ductal dilation (48% vs 37%), ductal calculi (44% vs 31%) and retained stones (7% vs 3%).

Compartment syndrome of the thigh. A case report and review of the literature

A case of compartment syndrome of the thigh following a gunshot injury that resulted in significant morbidity is presented. Early diagnosis of this uncommon condition requires a high index of suspicion in order to reduce morbidity and mortality. Timely diagnosis, emergency three-compartment decompression, prophylaxis against reperfusion syndrome and aggressive rehabilitation are necessary for a favourable outcome.